Introduction A future healthy world is highly associated with the children and their mothers, the Millennium Development Goals (MDGs) prioritize the child and maternal health with the targets “the under-five mortality rate should be reduced by two thirds from 1990 to 2015”. A transform program in the Philippines, launched by a NGO, aims to change the life of ultra-poor, and the interventions’ impact was measured in this study. Method The study selected participants who had completed the surveys in the short term (n=2183) and long term (n=196). The Chi-square test, Cochran-Armitage trend test, and Generalized Estimating Equation (GEE) model were applied to examine the hypotheses: (1) the program would have positive impacts on child health, (2) the child mortality is related to the maternal social-demographic factors and health behaviors. In the GEE model, the univariate and multivariate binary logistic regression was used to estimate the crude and adjusted odds ratio (OR). Result The univariate and multivariate analysis both show the maternal age is closely associated with the child mortality, and the child mortality of older women is higher than the younger in the short term survey (univariate: OR:8.36, 95%CI:4.17-16.77, multivariate: OR: 8.89, 95%CI: 4.27-18.54). In the long term, the results demonstrate that the child mortality of delivering in hospital (OR:0.29, 95%CI:0.11-0.76) and birthing home (OR: 0.46, 95%CI: 0.21-0.98) both lower than home (reference group). Compared to Bacolod, the child mortality rate of Gensan and Koronadal is lower in the short term. We found no difference in other maternal social-demographic factors and health behaviors. During the survey period, the literacy, PhilHealth, institutional delivery, delivery care provider, postnatal home visits, breastfeeding, and child mortality all improved, and the improvements of PhilHealth, postnatal home visits, breastfeeding were statistically significant. Conclusion The findings suggest that the program needs to constantly deliver more community-based interventions, such as: institutional delivery, skilled birth attendance, postnatal care, which would transform the children health of ultra poverty in the long run. / published_or_final_version / Public Health / Master / Master of Public Health

The ultra-processing of food has become a much more important aspect of dietary patterns and dietary quality in terms of its impact on body weight, diet related diseases, health, and well-being in the past decades. NOVA is a set of guidelines developed that classifies diet quality by degree of food processing. The NOVA guidelines distinguish four categories: unprocessed /minimally processed foods; culinary ingredients; processed foods; and ultra-processed foods. Numerous studies have found an association of ultra-processed foods and health conditions such as obesity and metabolic syndrome. This study analyzed the associations between maternal diet quality as measured by NOVA and maternal anthropometric and neonatal body composition outcomes. The optimal method of nutrition intervention and education for this special population remains unknown; using NOVA may provide researchers with a different lens to assess diet quality and health care professionals with additional vocabulary to convey more tailored messages regarding optimal nutrition strategies for mother and offspring. Using data collected from a large randomized controlled intervention trial at pre and post intervention, this study aimed to compare the NOVA guidelines assessment of maternal diet quality to the parent study assessment of diet quality, the Healthy Eating Index (HEI), using statistical correlations. Secondly, this study aimed to look at the relationship of ultra-processed food intake to the maternal gestational weight gain experience using a logistic regression. Thirdly, this dissertation aimed to explore the relationship between maternal ultra-processed food intake and neonatal lean mass as measured by quantitative magnetic resonance (QMR) and fat free mass as measured by air displacement plethysmography (ADP: PEAPOD). In terms of maternal outcomes, the study found that NOVA and HEI were significantly correlated at pre intervention but not at post intervention. The odds of gaining excessive gestational weight decreased as maternal ultra-processed food intake increased - which was not in the hypothesized direction - when using study participant data. However, the odds of gaining excessive gestational weight increased as maternal ultra-processed food intake increased - which was in the hypothesized direction - when using the Institute of Medicine weight gain recommendations. Also, while obesity did not predict excessive gestational weight gain, those with obesity ultra-processed food intake did predict gestational weight gain. These various inconsistencies are likely due to the instability of the dietary intake data because only one 24 -hour dietary recall was obtained from mother. In addition, the mothers’ diets were very healthy to begin with, where ultra-processed food intake formed about 45% of calories both pre and post intervention, when the national average is 57%. Race was also significant predictors of gestational weight gain for the mothers. Being non-white significantly increased the odds of gaining excessively as did the interaction of having obesity and eating more ultra-processed foods. In terms of neonatal outcomes, findings from this study suggest that length and fat mass are significant predictors of lean mass in neonates. In terms of the impact of maternal ultra-processed food intake, the higher the consumption of ultra-processed food, the greater the neonatal lean mass, which this was not in the hypothesized direction. However, the association was minimal with very small beta weights and regression line, when plotted was quite flat, so that the finding is not clinically meaningful. It remains important to know whether maternal ultra-processed food intake influences gestational weight gain and the body composition of the neonate. Thus, future research should include using similar data analyses on a population with a more nationally representative diet, a larger sample size, and a more robust measure of dietary intake such as three 24-hour recalls. Given that a similar recent study found ultra-processed food to be highly predictive of maternal and neonatal outcomes, and many other studies have demonstrated that ultra-processed food is related to several health conditions in many countries that this study did not measure, it seems prudent for healthcare providers to take advantage of prenatal visits as a window of opportunity to encourage the consumption of unprocessed and minimally foods and help women make informed decisions regarding ultra-processed foods.

Reducing health disparities and achieving health equity in maternal and infant health is a critical concern for social work and public health stakeholders more generally. This three-paper dissertation is dedicated to exploring program or policy modifiable social determinants of maternal and infant health with a particular focus on vulnerable populations. Paper one explores the influence of household members on women’s sexual and reproductive behaviors. Paper two studies the impact of smoke-free regulations on birth outcomes in Latin America. Lastly, paper three looks at the effects of police use of force, and racialized police use of force, on maternal and infant health. The findings of these papers provide important information to inform programs and policies aimed at improving reproductive health and well-being in the U.S. and Latin America.

Ghana is identified among the developing countries with high maternal mortality ratio in Africa. This study unpacked the Demographic and Health Survey data by examining the maternal health indicators at the district level using GIS methods. Understanding the geographic patterns of antenatal care, place of delivery, and skilled birth attendants at the small scale will help to formulate and plan for location-specific health interventions that can improve maternal health care behavior among Ghanaian women. Districts with high rates and low rates were identified. Place of residence, Gini-Coefficient, wealth status, internet access, and religious affiliation were used to explore the underlying factors associated with the observed patterns. Economic inequality was positively associated with increased use of maternal health care services. The ongoing free maternal health policy serves as a cushion effect for the economic inequality among the districts in the Northern areas. Home delivery is common among the rural districts and is more prominent mostly in the western part of Northern Region and southwest of Upper West. Educating women about the free maternal health policy remains the most viable strategy for positive maternal health outcomes and in reducing MMR in Ghana.

This dissertation addresses three separate questions in human capital and development economics. In the first chapter, I study how college admission concerns drive students' field choices in a field-specific college admission system. To study this question, I leverage a college admission policy reform in Ethiopia that sharply increased the proportion of college seats in public universities allocated to college STEM fields. The reform significantly decreased the admission selectivity of STEM fields in the short run. Using cohort analysis and a regression discontinuity design, I show that students are significantly more likely to choose the STEM fields after the reform. More importantly, I find significant heterogeneity in the field choice response, with the marginal students responding more strongly compared to the infra-marginal students. In addition, using a complier characteristics analysis, I show that the reform led to a significant sorting on field-specific skills. In particular, those induced to choose the STEM fields have a comparative advantage in skills valued more in the STEM fields. These overall and field-specific sorting significantly changed the peer quality in STEM and non-STEM fields. These findings imply that admission concerns play a significant role in students' field choices. However, students do not naively sort into less selective college fields. Instead, their choices are consistent with their relative position in the distribution of multi-dimensional skills. The latter suggests that students make more informed and rational choices than the existing literature suggests. In the second chapter, I investigate the effect of the fast expansion of the Second Generation (2G) and Third Generation (3G) mobile technologies in Sub-Saharan Africa (SSA) on health literacy in the region. Using Demographic and Health Surveys data from 25 countries in SSA and a historical mobile network coverage map, I estimate an Instrumental Variable (IV) specification. I show that the widespread use of these technologies has significantly improved health literacy in the region. Specifically, access to either technology significantly decreases misconceptions and wrong beliefs about diseases and health. The benefits are substantial in regions where the technologies have been available longer. Consistent with the range of services it provides, 3G technology results in a larger gain in health literacy. These findings imply that mobile technologies have considerable potential to improve health and quality of life in many developing countries. In the final chapter, I study the relationship between birth spacing and children's outcomes, focusing on the mechanisms that underlie the relationship. Using linked mother-child data from the National Longitudinal Survey of Youth (NLSY), I explore two mechanisms: the maternal health and physiology channel and the material and parental time input channel. The result shows that a short pre-birth inter-pregnancy interval negatively affects the birth endowments of children, highlighting the importance of the birth spacing effect that works through the maternal health and physiology channel. The study also provides evidence in support of the material and parental time input channel. In particular, I show that closely spaced siblings score significantly lower on the standardized Peabody International Achievement Test (PIAT), a wide-range measure of academic achievement for children aged five and above. On the other hand, I find limited evidence of the birth spacing effect on long-term outcomes such as schooling and labor market outcomes. These findings have implications for parental leave and other labor market policies affecting the birth spacing choices of parents.

In this dissertation I analyze patterns of maternal-infant health in developing contexts. My first chapter uses child hemoglobin as a bio-marker for maternal malnutrition in Senegal during the 2008 food price crisis. In early 2008, world rice prices skyrocketed, causing people around the world to plunge into poverty. Senegal, in particular, depends heavily on imported foodstuffs. I find that the crisis had a large, negative impact on child anemia in urban Senegal, most likely reflecting a deterioration of maternal nutrition caused by rising food prices. In the second and third chapters, we introduce a novel indicator of maternal-infant health: childhood sex ratios. Because infant females have lower rates of mortality than infant males, the sex ratio of the surviving population reflects the level of infant mortality. Childhood sex ratios are widely available from census data, meaning we can use them to shed new light on historical populations who lack traditional sources of data on infant mortality, like birth and death records. We apply this new method to the 19th-century US, where the lack of vital statistics has left uncertainty over even approximate levels of infant mortality. We find that the level of infant mortality in the pre-industrial US was much lower than previously thought, but that racial health disparities were much greater.

This dissertation consists of three empirical essays investigating different aspects of health care for children and families. The first essay examines the effectiveness of adherence to American Academy of Pediatrics guidelines for preventive pediatric health care. Using a national longitudinal sample of children age two years and younger, we investigate whether compliance with prescribed periodic well-child care visits has beneficial effects on child health. We find that increased compliance improves child health. In particular, higher compliance lowers future risks of fair or poor health, of some history of a serious illness and of having a health limitation. The second essay examines child health care utilization in relation to maternal labor supply. We test the hypothesis that working-mothers trade off the advantages of greater income against the disadvantages of less time for other valuable tasks, such as seeking health care for their children. This tradeoff may result in positive, negative, or no net impacts on child health investment. We estimate health care demand regressions that include separate variables for mother’s labor supply and her labor income. Our results indicate that higher maternal work hours reduce child health care visits; higher maternal earnings increase them. In addition, wage-employment, as opposed to self-employment, is detrimental to child health investment. A further finding is that preventive care demand for younger children is less sensitive to maternal time and income changes. We also find that detrimental time effects dominate beneficial income effects. The third essay studies intra-household resource allocation as it pertains to its demand for preventive medical care. We test the income-pooling hypothesis of the common preference model by using individual specific medical care consumption data and present evidence on the allocation of household resources to the medical needs of the child, husband and wife. Our results are in line with the findings of previous studies that emphasize the ongoing importance of the traditional gender role of woman as the primary caregiver. We find that the resources of the wife have a greater positive impact on child’s and her own preventive care demand than does the resources of the husband. In contrast to most studies from developing countries, we find that US families do not exhibit differential health care demand based on child gender. It is also noteworthy that the wife’s education level has a greater positive impact than that of her husband does on both the husband’s and her own preventive care utilization. / text

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